Clinical Policy: Asfotase Alfa (Strensiq) Reference Number: CP.PHAR.328 Effective Date: Last Review Date: 11.17

Transcription

1 Clinical Policy: (Strensiq) Reference Number: CP.PHAR.328 Effective Date: Last Review Date: Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description Asfotase alfa (Strensiq ) is a tissue nonspecific alkaline phosphatase. FDA Approved Indication(s) Strensiq is indicated for the treatment of patients with perinatal/infantile- and juvenile-onset hypophosphatasia (HPP). Policy/Criteria Provider must submit documentation (which may include office chart notes and lab results) supporting that member has met all approval criteria It is the policy of health plans affiliated with Centene Corporation that Strensiq is medically necessary when the following criteria are met: I. Initial Approval Criteria A. Perinatal/Infantile- and Juvenile-Onset Hypophosphatasia (must meet all): 1. Diagnosis of perinatal/infantile- or juvenile-onset HPP as evidenced by all of the following (a, b, and c): a. Age of onset is < 18 years; b. Presence of one of the following laboratory indices (i or ii): i. Mutation in the ALPL gene encoding for tissue non-specific alkaline phosphatase (TNSALP)*; ii. Serum alkaline phosphatase (ALP) below the age-adjusted normal range and either of the following (a or b): a) Plasma pyridoxal 5 -phosphate (PLP; main circulating form of vitamin B6) above the upper limit of normal (ULN); b) Urinary phosphoethanoloamine (PEA) above the ULN; c. History of one of the following HPP clinical manifestations (i, ii, iii, or iv): i. Vitamin B6-dependent seizures; ii. Failure to thrive or growth failure/short stature; iii. Nephrocalcinosis with hypercalcemia/hypercalcuria; iv. Skeletal abnormalities and associated impairments (any of the following): a) Craniosynostosis (premature fusion of one or more cranial sutures) with increased intracranial pressure; Page 1 of 5

2 b) Rachitic chest deformity (costochondral junction enlargement seen in advanced rickets) with associated respiratory compromise; c) Limb deformity with delayed walking or gait abnormality; d) Compromised exercise capacity due to rickets and muscle weakness; e) Low bone mineral density for age with unexplained fractures; f) Alveolar bone loss with premature loss of deciduous (primary) teeth; 2. Prescribed by or in consultation with an endocrinologist; 3. Dose does not exceed the following (a or b): a. Perinatal/infantile-onset HPP: 9 mg/kg in split doses per week; b. Juvenile-onset HPP: 6 mg/kg in split doses per week. Approval duration: 6 months *TNSALP is an ALP isoenzyme; a functional mutation in the gene (ALPL) encoding for TNSALP results in low TNSALP activity (as evidenced by a low serum ALP level) and increased levels of TNSALP substrates (PLP and PEA). B. Other diagnoses/indications 1. Refer to CP.PHAR.57 if diagnosis is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized). II. Continued Therapy A. Perinatal/Infantile- and Juvenile-Onset Hypophosphatasia (must meet all): 1. Currently receiving medication via Centene benefit or member has previously met initial approval criteria; 2. Member is responding positively to therapy, as evidenced by improvement in any of the following on initial re-authorization request: a. Height velocity; b. Respiratory function; c. Skeletal manifestations (e.g., bone mineralization, bone formation and remodeling, fractures, deformities); d. Motor function, mobility, or gait; 3. If request is for a dose increase, new dose does not exceed the following (a or b): a. Perinatal/infantile-onset HPP: 9 mg/kg in split doses per week; b. Juvenile-onset HPP: 6 mg/kg in split doses per week. Approval duration: 12 months B. Other diagnoses/indications (must meet 1 or 2): 1. Currently receiving medication via Centene benefit and documentation supports positive response to therapy. Approval duration: Duration of request or 6 months (whichever is less); or 2. Refer to CP.PHAR.57 if diagnosis is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized). III.Diagnoses/Indications for which coverage is NOT authorized: Page 2 of 5

3 A. Non-FDA approved indications, which are not addressed in this policy, unless there is sufficient documentation of efficacy and safety according to the off label use policy CP.PHAR.57 or evidence of coverage documents. IV. Appendices/General Information Appendix A: Abbreviation/Acronym Key ALP: alkaline phosphatase FDA: Food and Drug Administration HPP: hypophosphatasia PEA: phosphoethanoloamine PLP: pyridoxal 5 -phosphate TNSALP: tissue non-specific alkaline phosphatase ULN: upper limit of normal V. Dosage and Administration Indication Dosing Regimen Maximum Dose Perinatal/infantileonset HPP 6 mg/kg SC per week as either: 9 mg/kg per week 2 mg/kg three times per week, or 1 mg/kg six times per week Juvenile-onset HPP The dose may be increased for lack of efficacy (e.g., no improvement in respiratory status, growth, or radiographic findings) up to 9 mg/kg per week, administered as 3 mg/kg SC three times per week. 6 mg/kg SC per week as either: 2 mg/kg three times per week, or 1 mg/kg six times per week 6 mg/kg per week VI. Product Availability Single-use vials: 18 mg/0.45 ml (0.45 ml), 28 mg/0.7 ml (0.7 ml), 40 mg/ml (1 ml), 80 mg/0.8 ml (0.8 ml) VII. References 1. Strensiq Prescribing Information. Cheshire, CT: Alexion Pharmaceuticals, Inc.; October Available at Accessed August 30, Beck C, Morback H, Stenzel M. Hypophosphatasia: Recent advanced in diagnosis and treatment. Open Bone J. 2009; 1: Scott LJ. Asfotase alfa in perinatal/infantile-onset and juvenile-onset hypophosphatasia: A guide to its use in the USA. Bio Drugs. 2016; 30: DOI /s x. 4. Whyte MP, Rockman-Greenberg C, Ozono K, et al. Asfotase alfa treatment improves survival for perinatal and infantile hypophosphatasia. J Clin Endocrinol Metab. January 2016; 101(1): doi: /jc Epub 2015 Nov Orimo H. Pathophysiology of hypophosphatasia and the potential role of asfotase alfa. Ther Clin Risk Manag. May 17, 2016; 12: doi: /TCRM.S ecollection Page 3 of 5

4 6. Mornet E, Nunes ME. Hypophosphatasia. GeneReviews [Internet]. Seattle (WA): University of Washington, Seattle; Nov 20 [updated 2016 Feb 4]. Available at Accessed August 30, Bishop N. Clinical management of hypophosphatasia. Clin Cases miner Bone Metab. 2015; 12(2): Reviews, Revisions, and Approvals Date P&T Approval Date New policy developed, specialist reviewed Policy converted to new template. Authorization limits extended from 3 and 6 months to 6 and 12 months for initial and continued approval, respectively. Prescriber requirement added Important Reminder This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. Health Plan means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan s affiliates, as applicable. The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures. This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time. Page 4 of 5

5 This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. This clinical policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan. This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services. Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy Centene Corporation. All rights reserved. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene and Centene Corporation are registered trademarks exclusively owned by Centene Corporation. Page 5 of 5